重症患者的镇痛镇静治疗

重症患者的镇痛镇静治疗,黑龙江省重症医学科医疗质量控制中心哈尔滨医科大学附属第一医院 重症医学科费东生,我们的工作环境,镇静镇痛,Canadian survey of the use ofsedatives , analgesics , and neuromuscular blocking agent s in critically ill patients. Crit Care Med , 2006Mehta S , Burry L , Fischer S , et,A total of 273 of 448 eligible physicians (60%) responded. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents.,The incidence of ICU uncomfortable events was as high as 96.9 % in the recruited 163 cases. 83 of 163 patients (50.9 %) experienced severe uncomfortable events (SUE) . Patients received MV longer than 48 hours showed a slight higher incidence of SUE, with no statistical significance , compared with those patients received MV less than 48 hours (59.7 % vs 44.8 %, P 0.05) . 61 patients received no sedatives nor analgesics showed significantly higher incidence of SUE compared with those patients received either sedatives or analgesics (73.8 % vs 37.3 %, P 0.01) .Systemic sedation based on analgesics could effectively protect patients from SUE (OR: 0.125 ; 95 %CI : 0.052 0.298 ; P 3d)镇静，丙泊酚与咪唑安定相比，丙泊酚苏醒更快、拔管更早。在诱导期丙泊酚较易出现低血压，而咪唑安定易发生呼吸抑制，用药期间咪唑安定可产生更多的遗忘。,指南推荐：,丙泊酚PK咪唑安定,对急性躁动病人可以使用咪唑安定或丙泊酚来获得快速的镇静需要快速苏醒的镇静可选择丙泊酚短期的镇静可选用丙泊酚或咪唑安定,指南推荐：,丙泊酚PK咪唑安定,国外医学护理学分册2003年第22卷第11期,丙泊酚PK咪唑安定,Intensive Care Med,1997;23(12):1258-1263,丙泊酚+咪唑安定,咪唑安定-异丙酚序贯治疗“三明治”方案：即开始和停止镇静前应用丙泊酚，期间使用咪唑安定以提供相似的有效镇静以减少丙泊酚的用量，并减少彼此的不良反应。,咪唑安定具有镇静效果确切、顺应性遗忘作用以及价格便宜等优势,而在患者唤醒前4h 改用异丙酚镇静,可充分发挥其苏醒快的特点,避免苏醒延迟引起患者躁动以及循环波动,提高机械通气患者镇静及每日唤醒安全性。具体用法是: 首先在510 min内经静脉泵入丙泊酚100200 mg诱导患者进入理想的镇静水平,然后以最小有效的泵注速度泵入咪唑安定维持适宜的镇静深度,最后在停止机械通气前4 h左右停用咪唑安定,改用丙泊酚维持平稳的镇静效果,直至停用机械通气。,Sequential administration with midazolam-propofol effectively improved the daily arousal safety of patients with mechanical ventilation. 2007,反馈-调节,镇静深度的观察及调节 所有患者每2-4h 进行镇静深度评价，调整药物泵入剂量使躁动-镇静评分(agitation sedation scale , SAS) 维持在3-4 分/Ramsay scale ：3-4级,每日唤醒（daily interruption),所有患者均于每日固定时间停止泵入所有镇静、镇痛药至完全唤醒。评价标准为呼唤能睁眼，并能完成指令动作。达到标准后进行脱机评价(自主呼吸实验SBT) 。对不能脱机者按停药前1/ 2 剂量开始镇静-镇痛治疗，并逐步调节药物泵入量至镇静目标。,推荐意见10: 对接受镇静治疗的病人，应提倡实施每日唤醒计划。 ( A级),镇痛镇静,镇痛镇静,推荐意见11：镇静药长期( 7d)或大剂量使用后，停药过程应逐渐减量以防戒断症状出现。( C 级),撤离：,镇痛镇静治疗中